Page 119 - An Evidence Review of Active Surveillance in Men With Localized Prostate Cancer

of disease progression). However, the studies reviewed largely ignored this distinction or had
insufficient data to make this distinction and assessed adherence by reporting “interruption of
a
AS” to seek definitive treatments. The one exception was those studies that assessed patient
anxiety leading to curative treatment despite not meeting disease progression criteria.

Physician Factors (Appendix Tables C3.1–3.3)

Primary Care
Offer of AS. No study specifically examined how the involvement of a primary care physician in
the decisionmaking process might affect the offer of AS.
One survey of 381 New Zealand general practitioners given clinical vignettes reported that
45 percent of general practitioners would recommend WW if a patient’s life expectancy was less
than 10 yr, but only 3 percent would recommend WW if a patient’s life expectancy was more
than 10 yr. 184

Acceptance of AS. No study specifically examined how a patient’s primary care physician might
b
affect the acceptance of AS.
Three survey/interview-type studies (sample sizes were 25, 183 102, 187 and 185 122 ) reported
that physician recommendation (urologists or radiation oncologists) was the most influential
factor in a patient’s decision (30 percent in Holmboe 2000; 187 73 percent in Gorin 2011; 122 no
quantitative data were available in Davison 2009 183 ) to elect or not elect AS. Two other surveys
of men with prostate cancer (sample sizes were 654 185 and 231 190 ) reported that physician
recommendation (urologists, radiation oncologists, and others) was most influential in reaching a
treatment decision (51 percent 185 and 57 percent 190 ). However, one multivariable analysis of men
in the Prostate Cancer Research International: Active Surveillance study (PRIAS) reported that
patients who perceived that physician played the most important role in shared decision-making
process also had higher decisional conflict (more doubts) regarding the patient’s choice of AS
(“This suggests that men who perceive that they have actively participated in the treatment
decision-making process have fewer doubts regarding their treatment decision”). 181

Adherence to AS. No study specifically examined how a patient’s primary care physician might
affect adherence to AS. However, one survey of 53 men on AS who ultimately received
treatment reported that 81 percent believed that treatment was favored by their physicians
(urologists, radiation oncologist, medical oncologist, primary care physician), which was the
primary cause of the change in plan for AS. 186 In contrast, physician notes revealed that for only
24 percent of the patients was there documentation that the physician recommended treatment
due to clinical or biochemical evidence of tumor progression, leading to the study’s conclusion
that physicians more often perceive that patients themselves initiated the treatment decisions.

a We do not know the proportion of non-adherence. We do know that the proportion of patients on AS who went on
to receive active treatments ranged from 16 to 54 percent with a median followup of 1 to 7 years (see Appendix
Table C5.1).
b We are aware of one age- and comorbidity-stratified analysis of 85,088 men with clinically localized disease
identified from the SEER-Medicare database which concluded that men who saw a primary care physician after
diagnosis were more likely to have AS/WW than those who did not (e.g., for men aged 75-79 years with
198
comorbidity index of ≥2, 76.5 vs. 12.2 percent, see original paper for results from other categories). This study
did not meet our multivariable analysis inclusion criterion.

65